ZOUVES FERTILITY CENTER PATIENT SERVICES
1241 E. HILLSDALE BLVD., SUITE 100, FOSTER CITY, CA. 94404
TOLL FREE: 1-800-800-1160 PHONE: 650-378-1050 FAX: 650-577-1112
IN ORDER TO SCHEDULE A CONSULTATION WITH A DOCTOR, AN OVERVIEW OF YOUR MEDICAL HISTORY AND A COPY OF YOUR
MEDICAL RECORDS ARE REQUESTED. THIS WILL INSURE THAT THE DOCTOR CAN ASSESS YOUR INDIVIDUAL CASE DURING
YOUR INITIAL CONSULTATION. PLEASE FILL OUT THIS FORM AND EMAIL TO [email protected]OR FAX TO 650-577-1112 FEMALE CONSULTATION QUESTIONNAIRE
LEGAL NAME (PLEASE PRINT)?
NAME:________________________________DATE OF BIRTH:_____________________________________ DO YOU PREFER TO GO BY ANOTHER NAME________________________________________________________
WHAT IS YOUR MAILING ADDRESS (INCLUDE CITY, STATE AND ZIP CODE)? WHAT ARE YOUR PHONE NUMBERS? (INCLUDE AREA CODE)
HOW WERE YOU REFERRED TO US? PHYSICIAN PATIENT RADIO NEWSPAPER WORD OF MOUTH INTERNET
OTHER ______________ WHICH PHYSICIAN OR PATIENT IF APPLICABLE________________________________
LAST CONTRACEPTIVE USED: ________________________________STOPPED:__________________________ HAVE YOU DONE ANY ACUPUNCTURE: YES NO__________________________________________________ ACUPUNCTURIST NAME: ___________________________________________ HERBS: ___________________
ARE YOU ALLERGIC TO ANY MEDICATIONS?
ARE YOU CURRENTLY TAKING ANY MEDICATIONS OR SUPPLEMENTS? PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS _____________________________________________________________________________________ HAVE YOU EVER BEEN PREGNANT (LIVE BIRTH, MISCARRIAGE (SAB), TERMINATION (TAB), CHEMICAL OR ECTOPIC) YES □ NO □
A) TOTAL NUMBER OF PREGNANCIES____ LIVE BIRTH(S) _____ MISCARRIAGE(S) _____ TERMINATION(S) _____ ECTOPIC(S) _____
B) DATES OF PREGNANCY: PLEASE INCLUDE HOW MANY WEEKS, WITH CURRENT OR PREVIOUS PARTNER, RESULT, AND THROUGH NATURAL CONCEPTION OR ASSISTED REPRODUCTION.
PREGNANCY #1____________________________________________________________________
PREGNANCY #2____________________________________________________________________
PREGNANCY #3____________________________________________________________________
PREGNANCY #4____________________________________________________________________
PREGNANCY #5____________________________________________________________________
WHAT HAVE THE DOCTORS DIAGNOSED AS THE INFERTILITY PROBLEM? (PLEASE MARK WITH AN X)
_____ENDOMETRIOSIS (MILD, MODERATE OR SEVERE?)
DOCTOR’S NAME: _________________________________________YEAR DIAGNOSED ________________
ARE YOU CURRENTLY IN CYCLE WITH ANOTHER FERTILITY CENTER? ___________________________________
FEMALE HISTORY
WEIGHT________________________________________HEIGHT_______________________________
HOW OLD WERE YOU WHEN YOU STARTED YOUR MENSTRUATION? ____________________________________ HOW LONG BETWEEN MENSTRUATION (EXAMPLE: EVERY 28 TO 30 DAYS)?______________________________ HOW MANY DAYS DOES YOUR MENSTRUATION LAST (ACTUAL DAYS OF BLEEDING)? _________________________ HAVE YOU BEEN DIAGNOSED WITH ANY OVULATION PROBLEMS OR HORMONAL IMBALANCES? __________________
HAVE YOU BEEN TESTED FOR THE FOLLOWING HORMONES? IF YES, MARK ANY ABNORMAL OR NORMAL RESULTS. FOLLICLE STIMULATING HORMONE (FSH) __________ESTRADIOL(E2)_________________________________ THYROID HORMONES (TSH)___________________ ANTI-MULLERIAN HORMONE(AMH)___________________
PROLACTIN______________________________ PROGESTERONE_________________________________
HAVE YOU EVER UNDERGONE ONE OR MORE OF THE FOLLOWING PELVIC SURGERIES?
SURGERY TO REPAIR OVARIES OR UNBLOCK TUBES YES NO __________________________________
ECTOPIC PREGNANCY/SURGERY YES NO _______________________________________________
TUBAL LIGATION YES NO _________________________________________________________
ENDOMETRIOSIS (STAGE I, II, OR III)? (PLEASE CIRCLE) YES NO _____________________________
REMOVAL OF SCAR TISSUE, POLYPS, CYSTS, ETC. FROM INSIDE OF UTERUS YES NO __________________
REMOVAL OF FIBROIDS FROM UTERUS YES NO ___________________________________________
HYSTERECTOMY/REMOVAL OF OVARIES YES NO __________________________________________
HAVE YOU EVER HAD A HYSTEROSALOPINOGRAM (HSG)? (DYE IS INSERTED INTO TUBES AND AN X-RAY IS PERFORMED). IF YES, WHAT YEAR WAS THE TEST PERFORMED AND WHAT WERE THE FINDINGS? WERE THE TUBES CLEAR BLOCKED? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ DOCTOR’S NAME _____________________________________YEAR ______________________________
HAVE YOU HAD A LAPAROSCOPY? (THIS IS A MINOR SURGERY. A SMALL INCISION IS MADE NEAR THE BELLY BUTTON). IF YES, WHAT YEAR AND WHAT WERE THE FINDINGS? __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’S NAME ____________________________________ YEAR _____________________________
HAVE YOU HAD A HYSTEROSCOPY? (THIS IS A NON-SURGICAL MEANS OF LOOKING AT THE MUSCLE WALL OF THE UTERUS. A TELESCOPIC INSTRUMENT IS INSERTED VAGINALLY). IT IS NOT AN ULTRASOUND. IF YES, WHAT YEAR AND WHAT WERE THE FINDINGS? __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’S NAME ____________________________________ YEAR _____________________________
HAVE YOU HAD A HYSTERO-ULTRASONOGRAM (HUS)? (STERILE WATER IS INSTILLED INTO THE UTERINE CAVITY AND AN ULTRASOUND SCANNER CHECKS FOR POLYPS OR FIBROIDS) __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’SNAME_____________________________________YEAR______________________________ HEALTH HISTORY
POSITIVE PPD PURIFIED PROTEIN DERIVATIVE YES___
FAMILY HISTORY
ETHNIC ORIGIN/ANCESTRY MOTHERS ANCESTRY: ___________ FATHER: ______________________________ DO YOU HAVE ANY OF THE FOLLOWING HERITAGES? PLEASE X IN THE BOX BELOW
PLEASE LIST-- MATERNAL/PATERNAL GRANDMOTHER, GRANDFATHER, MOTHER, FATHER, BROTHER, SISTER, AUNT OR UNCLE, ETC. Hereditary Conditions
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
______________________________________ NO
PAST FERTILITY TREATMENT
25. HAVE YOU BEEN TREATED WITH THE FOLLOWING?
CLOMID/SEROPHENE/FEMERA: ______________________ IF SO, HOW MANY CYCLES TOTAL? ______________ INJECTABLE GONADOTROPINS: ______________________ IF SO, HOW MANY CYCLES TOTAL? _____________
26. HAVE YOU UNDERGONE AN IUI CYCLE(S) IF SO, PLEASE LIST EACH CYCLE BELOW: CYCLE DR. & LOCATION IVF HISTORY PLEASE LIST EACH INDIVIDUAL IVF, FET OR ANY CANCELLED CYCLES INDICATE IF YOU USED YOUR OWN EGGS, EGG DONOR, SPERM DONOR, AND/OR SURROGATE, OR CYCLE WAS A FROZEN EMBRYO TRANSFER. PLEASE INCLUDE CANCELLED CYCLE(S) OR CYCLE(S) THAT TURNED TO IUI. CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ PLEASE NOTE ANY OTHER ITEMS THAT YOU WOULD LIKE TO HAVE DR. ZOUVES REVIEW:
2301-670 Graph theory 1.1 What is a graph? 1st semester 2550 1.1. What is a graph? 1.1.2. Definition . A graph G is a triple (V(G), E(G), ψG) consisting of V(G) of vertices , a set E(G), disjoint from V(G), of edges , and an incidence function ψG that associates with each edge of G an unordered pair of (not necessarily distinct) vertices of G. If e is an edge and u and v are
Treatment of head louse infestation with 4% dimeticone lotion: randomised controlled equivalence trial Ian F Burgess, Christine M Brown and Peter N Lee 2005;330;1423-; originally published online 10 Jun 2005; BMJ doi:10.1136/bmj.38497.506481.8F Updated information and services can be found at: References This article cites 10 articles, 1 of which can be accessed free at: 5 onlin